Sanitation MDG is badly off track, but a community-led approach could fix that

Vast sums are wasted on programmes for free toilets, but the community-led total sanitation approach has helped millions avoid often fatal, faecally related infections

Defecation mapping in progress in a village in the Democratic Republic of Congo, December 2010. This was set up by Tearfund and conducted by the CLTS team from Plan Kenya; 18 people attended this workshop, which 'triggered' action in six villages. Photograph: Philip Vincent Otieno/CLTS

Community-led total sanitation (CLTS) does not sound such a big deal, but it is revolutionary. We have so many "revolutions" in development that only last a year or two and then fade into history. But this one is different. In all the years I have worked in development this is as thrilling and transformative as anything I have been involved in. Let me explain.

Firstly, sanitation and scale: 2.6 billion people need improved sanitation and 1.1 billion defecate in the open. The millennium development goal (MDG) for sanitation is badly off track in most countries, which affects all the other MDGs.

Secondly, sanitation and hygiene matter much more than most people realise. Where they are lacking, the effects are horrendous. Faecally related infections are many. Everyone feels outrage because more than 2 million children are killed by diarrhoea each year. We hear about cholera outbreaks. But who hears about the guts of 1.5 billion people hosting greedy, parasitic, ascaris worms, about 740 million with hookworm voraciously devouring their blood, 200 million with debilitating schistosomiasis or up to 70 million with liver fluke? And what about dysentery, hepatitis, giardia, tapeworms, typhoid, polio, trachoma…?

On top of all these, many millions are affected by tropical enteropathy, where the gut wall is damaged and nutrient absorption is reduced – in effect, wasting food. All these can be dealt with through safe disposal of excreta and safe hygienic behaviour. We give undernourished children more, and better, food. Let that continue. But wouldn't improved sanitation and hygiene also, in many cases, lead to more effective and longer-lasting solutions for tackling undernutrition?

The traditional approach to hygiene has been education and subsidy: people have to be taught, and poor people cannot afford toilets. But rural areas in developing countries are littered with the results of failed programmes: toilets not used, put to other purposes as stores, hencoops, shrines and the like, or dismantled and materials used elsewhere. Or the toilets go to those who are better off, not the poor. The dollars wasted run into billions; and in some countries like India very large sums continue to go, so to speak, down the drain.

CLTS turns these failed approaches on their heads. There is no standard design, no hardware subsidy, no teaching, no special measures for people unable to help themselves, and no use of polite words – "shit" is "shit" (India leads in the international glossary of words for shit, with Kenya following). Communities are mobilised into analysing their own sanitation and waste behaviour, making their own participatory social and shit maps, inspecting the shit in the areas of open defecation (OD), and analysing pathways from shit to mouth. Often children make their own analysis in parallel with adults and then present their findings to them. When people realise "we are eating one another's shit", that can ignite immediate action to dig pits and construct latrines with their own resources.

A follow-up of encouragement, emphasising handwashing and hygiene as well as construction, is important. Ideally and often, those unable to dig and build for themselves are helped by others. It is in the common interest. When a community can declare itself ODF (open defecation free), external verification takes place, and then there is a celebration.

The CLTS approach was pioneered in Bangladesh in 2000 by Kamal Kar, a development consultant from India. Since then he has been joined by many others to promote it including Plan International, Unicef, the Water and Sanitation Programme of the World Bank and Water Aid. The approach has been adopted in more than 40 countries. In a few it has stalled, but in most it is spreading and is already widespread in parts of south and south-east Asia. Sierra Leone, Mali, Kenya, Ethiopia, Zambia and Malawi stand out in Africa. In more and more countries CLTS has been adopted as hardware subsidies to individual households have been stopped. Worldwide, after discounting heavily for misleading reports of targets achieved, more than 10 million people are now living in communities that have credibly been declared ODF.

CLTS is not a magic wand. It faces serious obstacles: entrenched, and large, budgets for hardware subsidies; professional and bureaucratic sceptics and vested interests; training of facilitators in classrooms when it needs to be done hands-on, in real time, in communities; programmes with targets that are then reported "achieved"; myths of success; donor and lender agencies insisting on subsidies; and the corruption that so often goes with hardware programmes.

But it is driven by passionate champions. Many become energetically committed once they have experienced the power of CLTS – how it enhances human wellbeing. For women and girls, in particular, it has helped with menstrual hygiene, self-respect, and the bodily wellbeing of being able to defecate during daylight, in private – which is a transformation for women in South Asia.

It is thrilling. It is an international movement, itself a community of like-minded people who are inspired by the vast potential of the CLTS approach. And it has applications, too, for solid and liquid waste management, and perhaps other domains.

While the focus for CLTS was initially in rural areas, in India, Kenya, Mauritania and Nigeria it is being advocated for urban slums. Kenya is rolling out a big programme and has set itself the target of making all rural areas ODF by 2013. Other countries are doing likewise. The questions now are how well it can be taken to scale, and whether enough people at all levels – from policy-makers to local leaders and facilitators – have the vision, guts and commitment to make it happen widely and well. The MDG for sanitation is badly off-track in almost all countries, but with CLTS it need not be.

By 2020, say, could it be not 10 million but hundreds of millions who benefit? Is it hyperbole to say that the opportunity is brilliant? What do you think?